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IN The Conversation earlier this year, Tim Baker described consultations with his oncologist: a distressing hour in the waiting room, and then the brief (ten minutes) and cursory consultation. Reading it was upsetting. I wanted him to have had the experience of an authentically engaged and caring clinical interaction. As Baker himself puts it: “The lack of opportunity for a more wide-ranging conversation … just feels wrong.”
I suspect if asked, most doctors would agree that empathy is important. However, we are also confident that the near $200 000 spent on empathy training for the previous Prime Minister, Scott Morrison, didn’t hit the spot. So perhaps the theory is easier to articulate than to put into practice. For me as a medical educator, two questions arise:
- What is and how do we teach empathy?
- How should (could) we assess empathy?
We could limit admission to medicine to students who already show a degree of empathetic thinking, who already cry for others. This would at least abbreviate the task. After all some politicians look entirely at ease when they cradle someone else’s baby (pre-pandemic), others never will, despite hours of coaching. However, to do this is to fail to see the opportunity for transformative education.
After years of involvement in medical education, I think the best outline of how empathy can be taught lies in the work by colleagues at the Māori Indigenous Health Institute (MIHI) at the University of Otago in Christchurch. They describe a framework to enhance the doctor–patient relationship with Māori. For this Hui Process, they draw “on traditional knowledge and practice [to align] it to a contemporary situation”. The principles are:
- Mihi: greeting and engagement;
- Whakawhānaungatanga: making the connection;
- Kaupapa: attending to the main purpose of the encounter; and
- Poroporoaki: concluding the encounter.
It is surely the whakawhānaungatanga that is particularly missing from Baker’s encounters with his oncologist. I remember the same feeling when pregnant. It was a long time ago – with no automated machines. My obstetrician would ask me how I was, as he put the stethoscope in his ears to take my blood pressure. It’s the dissatisfaction I’ve heard expressed by many patients and their families and carers, and many colleagues, particularly over the past 18 months.
Many years ago, I remember being faintly shocked at hearing the late Professor Ann Woolcock talk about her children with her patient – something she would never do with me, a laboratory technician at the time. I think what Baker (and so many others) hanker for is that sense of connection that Professor Woolcock, a respiratory physician, understood could come from sharing her story of parental experience.
These acts are not simply to be “nice”. Lacey and colleagues (2011) based their framework on traditional engagement within Māori cultural protocols, and it specifically requires some self-disclosure by the clinician about their own experiences. This is not to burden the patient with the woes of the treating clinician, but to share some small personal relevant matter that goes some way to reducing the power differences in the consultation. Whānau is the extended family or community of related families, although it is a more subtle and complex network of relationships and responsibilities. And “It is emphasised that whakawhānaungatanga is not a one off event and there is a need to attend to connecting with the patient and whānau throughout the consultation”.
If it is necessary to sustain the effort of connection throughout the consultation, Baker’s oncologist makes no effort at connection at all. The encounters strike his patient as short and “perfunctory. … More than anything, I’d like a bit more evidence that he cares”.
Baker’s oncologist has “a waiting room full of patients and is already running an hour behind schedule” and “he’s seeing dozens of patients every day at roughly ten-minute intervals”. In my experience it takes time and energy, to engage, to disclose, to listen, to pay heed, to care.
So, we will need to teach that engaging and caring takes time. Ten minutes won’t cut it.
Having taught it, included it in the curriculum, designed the resources, delivered the teaching – now to assessment. Are there objective measures for this? Do we need to use proxy measures? Should we set essays (oh, the marking!)?
I think the assessment of empathy is best done by the those receiving it. I haven’t broached a discussion of the definition of empathy here — because patients know. Every patient, Mr Baker, or anyone in any waiting room, or reading this article will know and intuitively assess the empathy of the clinician at their next consultation. Forget the multiple choice, “single-best-answer” questions. Forget the simulations. Let’s ask the people who will know best and who won’t be conned by smarm: the people we deliver care to. Let’s ask our patients and their families.
Dr Lilon Bandler is a Sydney-based GP, medical educator, and Associate Professor with the Leaders in Indigenous Medical Education Network at the University of Melbourne. She is Medical Director of health services at the Wayside Chapel.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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I believe most Doctors and Specialists have empathy and endeavour to express it to their patients. Always is a difficult expectation in any line of work, just ask a Chef….the demands of getting it right for every individual every time is extreme. Many Doctors are dealing with ever changing developments and increases in new surgical, pharmaceutical, and Hospital treatments, especially in Oncology, Urology and Paediatrics etc.
The knowledge and the experience are what is really pertinent at the end of the day. Specialists rely on many test results and observe a patient when present with them to design a plan that ensures best outcomes for any patient. I think we need to speak up at the time or take an advocate speak on your behalf. 9/10 times the Doctor may not be aware/exhausted/concerned/hopeful/ and for so many other reasons. (These are not excuses).
There is no KPI for empathy or compassion in my busy ED.
I feel that the public health system has turned us into a machine to churn “clients” through.
Oncologists (like myself) do not have to be “detached” – they can choose to have empathy. It is just a matter of caring enough about patient and family in order to do so. It takes very little extra time but more emotional energy.
Great article Lilon – and thank you for your teaching way back in the Northern Clinical school in the late 90s
Time is an issue.. what is the over burdened oncologist meant to do with so many patients.
He probably was not rude but quick . He has to get to the point quickly.
Alternatively he must cut down on the patients he sees.
For me though, I am grateful to be getting care.
Myself and a dedicated group of specialists have been teaching empathy and other communication skills via the RACP Palliative Medicine Communication Skills Workshop and other similar workshops for the last 10 years.
Empathy can be taught, as it is a set of skills. Sure, some are more skilled than others and I believe everyone can learn something towards becoming more empathic, as it is a human to human connection. Sadly this connection is often actively discouraged though our post grad training and is full of myths and assumptions around why we should not to respond to emotion.
I can be done in less than 10 minutes. It certainly doesn’t require any “personal story” from the clinician – in fact, this can have the exact opposite effect, where the patient experience is suddenly not the focus – we all have to listen to the clinicians issue!
Empathy is about sitting with or in the emotional distress of the other person and understanding how that is for them. Showing that we are not abandoning them by giving medical information, ignoring it or jumping in with our own stuff.
It can definitely be assessed by asking the patient how they were made to feel!
Fantastic article, Lilon. I agree with all that you have said.
Empathy doesn’t even need to take more time than rudeness. All of the simple parts of a consultation can show empathy.
Assessment is a challenge. Maybe the only way to assess it is to ask the patients. Simulated patients, patients on the wards during clinical assessments etc. should have input into the student’s score. This could occur all the way from med entry interviews to Fellowship exams. ‘How did the doctor make you feel?’
Anyone at any stage can be told to be empathetic. They can be told what empathy is. They can be told it is a good thing. They can be told empathy makes for good doctors.
The problem is in the implementation of empathy. There is no doubt that empathy is an innate personality trait that can be selected for when interviewing medical students, interns, registrars, and specialists alike. That should be the easy part!
The next problem is how to get people lacking in empathy to become empathetic. For those where empathy does not come naturally, like surgeons who have less prowess with soft tissue handling, people can endeavour to be as empathetic as they can. That takes a lot of time and effort on that person’s part to achieve something that administrators, bureaucrats, and non-medical government agencies (AHPRA) do not consider important. It takes a lot of time and effort on the part of the trainers and role models which rarely gets acknowledged by trainees, colleagues or administrators.
The one thing is sure – empathy is highly valued by patients.
Communication and empathy skills have been a focus in prospective medical student interviews in SA for years There will always be good , average and poor communicators as part of the normal human spectrum. Luckily medicine has many pathways including those with minimal patient contact. Medical Oncologists are dealing with cancer all day long, probably have to be a bit detached , often are under time pressure and have to be pretty matter of fact and direct in their approach. Aa surgeon referring patients I would warn them of this ahead of time